Measuring sexual violence stigma in humanitarian contexts: assessment of scale psychometric properties and validity with female sexual violence survivors from Somalia and Syria.

BACKGROUND: Valid measures of sexual violence stigma that can be readily incorporated into program monitoring and evaluation systems are needed to strengthen gender-based violence (GBV) services in humanitarian emergencies. This study sought to assess the psychometric properties, construct validity, and measurement invariance of sexual violence stigma scales among female Somali GBV survivors in Kenya and Syrian GBV survivors in Jordan to identify an abbreviated scale that could be used across humanitarian contexts. METHODS: We administered measures of sexual violence stigma to 209 female survivors of sexual violence aged 15 and older in Kenya and Jordan. Exploratory factor analysis was used to assess the underlying latent structure, and Item Response Theory was used to estimate item difficulty and discrimination parameters to guide efforts to shorten the scales. Differential item functioning (DIF) by site was assessed using Multiple Indicators, Multiple Causes models. Construct validity of the sexual violence stigma scales was assessed by estimating correlations with functional impairment, depression, and disability. RESULTS: The sexual violence stigma measure exhibited distinct factor structures among Somali and Syrian GBV survivors. Among Somali survivors, a two-factor model with separate felt (10 items) and enacted (4 items) stigma constructs was identified, with scales for both domains exhibiting good internal consistency (Cronbach's alpha = 0.93 and 0.88, respectively). In Jordan, a single factor solution was uncovered for a 15-item stigma scale with good internal consistency (alpha = 0.86). The shortened core sexual stigma scale consisting of the 4 items that did not exhibit DIF had a Cronbach's alpha of 0.82 in Kenya and 0.81 in Jordan. The felt stigma scale in Kenya, the full stigma scale in Jordan, and abbreviated core stigma scales in both countries were meaningfully correlated with depression, while correlations with functional impairment were weaker and inconsistent across scales. CONCLUSIONS: An abbreviated core set of invariant perceived and internalized sexual violence stigma items demonstrated evidence of construct validity in two diverse settings. The ability of this measure to be efficiently administered as a part of routine program monitoring and evaluation activities, with the potential addition of items from a measurement bank to improve contextual relevance, can facilitate improvements in the delivery and quality of gender-based violence programs in humanitarian emergencies.

Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study.

BACKGROUND: There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania. METHODS: A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention. RESULTS: Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE. CONCLUSIONS: The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.

Improving mental health in low-resource settings: A feasibility randomized controlled trial of a transdiagnostic psychological intervention among Burundian refugee adolescents and their caregivers.

There is a paucity of evidence regarding interventions that can improve the mental health of adversity-affected young adolescents living in low-resource settings. We evaluated the feasibility, acceptability, relevance, and safety of the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention among Burundian refugee adolescents and their caregivers in Tanzania. This study consisted of a feasibility cluster randomized controlled trial (cRCT) and a process evaluation. The feasibility cRCT included 82 young adolescents and their 64 caregivers, with two clusters randomized to EASE and two to an enhanced control condition. EASE was delivered by adult refugees without prior training in mental health. The process evaluation consisted of 36 semi-structured qualitative interviews with key stakeholders, including adolescents, caregivers, and facilitators. EASE participants and facilitators gave positive feedback about its format, accessibility, and content. Trained non-specialist refugee facilitators were able to deliver EASE with high fidelity. The research protocol functioned well in terms of balanced randomization, limited loss to follow-up, and psychometrically promising measures, but discordance was observed between the short screener and psychological distress symptom checklist. This formative study suggests the potential of EASE in targeting psychological distress among displaced young adolescents and lays the groundwork for a future definitive trial.

Girl Empower - A gender transformative mentoring and cash transfer intervention to promote adolescent wellbeing: Impact findings from a cluster-randomized controlled trial in Liberia.

BACKGROUND: We evaluated Girl Empower - an intervention that aimed to equip adolescent girls with the skills to make healthy, strategic life choices and to stay safe from sexual abuse using a cluster-randomized controlled trial with three arms: control, Girl Empower (GE), and GE+. METHODS: GE delivered a life skills curriculum to girls aged 13-14 in Liberia, facilitated by local female mentors. In the GE + variation, a cash incentive payment was offered to caregivers for girls' participation in the program. We evaluated the impact of the program on seven pre-specified domains using standardized indices: sexual violence, schooling, sexual and reproductive health (SRH), psychosocial wellbeing, gender attitudes, life skills, and protective factors. FINDINGS: Participation rates in the program were high in both GE and GE+, with the average participant attending 28 out of 32 sessions. At 24 months, the standardized effects of both GE and GE+, compared to control, on sexual violence, schooling, psychosocial wellbeing, and protective factors were small (ß, ≤ 0.11 standard deviations [SD]) and not statistically significant at the 95% level of confidence. However, we found positive standardized effects on Gender Attitudes (GE: ß, 0.206 SD, p<0.05; GE+: ß, 0.228 SD, p<0.05), Life Skills (GE: ß, 0.224 SD, p<0.05; GE+: ß, 0.289 SD, p<0.01), and SRH (GE: ß, 0.244 SD, p<0.01; GE+: ß, 0.372 SD, p<0.01; F-test for GE = GE+: p = 0.075). INTERPRETATION: Girl Empower led to sustained improvements in several important domains, including SRH, but did not reduce sexual violence among the target population.